‘He or she maybe doesn't know there is such a thing as a review’: A qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities

Abstract Introduction Regular reviews of medications, including prescription reviews and adherence reviews, are vital to support pharmacological effectiveness and optimize health outcomes for patients. Despite being more likely to report a long‐term illness that requires medication when compared to their white counterparts, individuals from ethnic minority communities are less likely to engage with regular medication reviews, with inequalities negatively affecting their access. It is important to understand what barriers may exist that impact the access of those from ethnic minority communities and to identify measures that may act to facilitate improved service accessibility for these groups. Methods Semi‐structured interviews were conducted between June and August 2021 using the following formats as permitted by governmental COVID‐19 restrictions: in person, over the telephone or via video call. Perspectives on service accessibility and any associated barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Health Research Authority (ref: 21/HRA/1426). Results In total 20 participants from ethnic minority communities were interviewed; these participants included 16 UK citizens, 2 refugees and 2 asylum seekers, and represented a total of 5 different ethnic groups. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medication reviews and identified approaches to improve the accessibility of such services for ethnic minority patients. These centred on (1) building knowledge and understanding about medication reviews; (2) delivering medication review services; and (3) appreciating the lived experience of patients. Conclusion The results of this study have important implications for addressing inequalities that affect ethnic minority communities. Involving patients and practitioners to work collaboratively in coproduction approaches could enable better design, implementation and delivery of accessible medication review services that are culturally competent. Patient or Public Contribution The National Institute for Health Research Applied Research Collaboration and Patient and Public Involvement and Engagement group at Newcastle University supported the study design and conceptualization. Seven patient champions inputted to ensure that the research was conducted, and the findings were reported, with cultural sensitivity.


| INTRODUCTION
Regular reviews of medication are vital to support medicine effectiveness and prescribing safety. [1][2][3] Previously, medication reviews have been defined as 'a structured, critical examination of a patient's medicines with the objective of reaching an agreement with the patient about treatment, optimizing the impact of medicines, minimizing the number of medication-related problems, and reducing waste'. 4,5 The Royal Pharmaceutical Society of the United Kingdom (UK) deems that conducting medication reviews is a key role for pharmacists and other appropriately trained members of the multidisciplinary team, including doctors and allied health professionals. 4 In doing so, medication review services address medicine optimization and adherence issues, as well as potentially improve the clinical effectiveness of medicines being taken. 4,[6][7][8][9] This study focuses on medication review services offered by healthcare professionals in the UK working in a primary care setting (e.g., a general practice surgery or community pharmacy), including prescription reviews and adherence and compliance reviews, rather than clinical medication reviews (which require access to clinical information and thus occur more readily in secondary care settings) or medicine use reviews (which have been discontinued). 10 Medication reviews may take the form of ad-hoc interventions, with a medication eligible for a New Medicines Service, or aligned with annual long-term condition reviews. 11,12 These medication review services may differ from those in other countries or healthcare settings, for example, Australian Home Medication Reviews 13 or Swiss Polymedication Checks. 14,15 Optimization of patient outcomes is an underpinning goal of all medication review services; however, inequalities affecting accessibility have been identified, particularly relating to ethnic minority communities. [16][17][18] A multitude of factors have been identified as contributors of health inequalities amongst ethnic minority populations, including lower health literacy levels, lower socioeconomic status and a greater incidence of ill-health. [19][20][21][22][23] The COVID-19 pandemic further highlighted these inequalities, particularly service accessibility. [24][25][26] Despite reporting poorer general health when compared to their white counterparts, 27 and despite being more likely to report a long-term illness that requires medication, 28 individuals from ethnic minority backgrounds are less likely to engage in regular medication reviews. 29,30 Despite the associations between accessibility inequalities and ethnicity, people from ethnic minority communities continue to remain underrepresented participants in health and social care research. 30,31 These findings can be demonstrated in high-income countries 27,32 including the United States of America, where financial burdens of health insurance and remotely delivered consultations during the COVID-19 pandemic have been reported barriers. [33][34][35] Evidence suggests that these inequalities also exist for medication reviews; this study sets out to extend the evidence on ethnic inequalities and accessibility in the context of medication reviews. When considering the value that medication reviews can offer in optimizing a person's medication, it is important to (i) understand what barriers may exist that impact the access of those from ethnic minority communities and to (ii) identify measures that may facilitate improved service accessibility for these groups.

| Recruitment and sampling
The consolidated criteria for reporting qualitative research (COREQ) checklist was followed (File S1). 36  participants over 18 years of age who self-identified as being from an ethnic minority background and living in the North East of England; who took one (or more) regular prescription medication(s); and who had the capacity to consent to taking part in the study. There was no requirement to communicate in the English language; interpreters were involved if required. Purposive sampling was used to recruit participants from different ethnic minority groups reflective of the communities living in the area; participants were of mixed age ranges and had varying sociodemographic and immigration backgrounds (including UK citizens, those with visas and those who were seeking asylum).

| Semi-structured interviews
Semi-structured interviews were conducted by one researcher (A. R., a female doctoral researcher with qualitative research experience) between June and August 2021. Interviews were conducted via video-call (Zoom ® ), telephone call or in person; all participants were offered the choice of their preferred format.
Interpreters were available as required, to support translation needs. The interview topic guide (File S1) was developed based on three pilot interviews and covered issues identified in previous research, 29,37 including participants' experiences of taking medicines; their understanding of medication reviews; their experiences of engaging with these reviews (either in the UK or in their home country); their perspectives of accessing medication reviews; potential barriers or facilitators that affect access; and recommendations for ways to address or improve on challenges. 38 The topic guide was also informed by the lived experiences of patient champions involved in this study (L. S., T. G. and H. K. G.).
For the purposes of this study, the exploration of medication review services will include those delivered by pharmacists, as well as other healthcare professional groups.

| Data analysis
All interviews were audio-recorded to enable data analysis. The audio files were encrypted and transferred electronically (via an electronic, password-protected drop box) to an external company to be transcribed verbatim. Interpreters were used in some interviews to facilitate three-way communication between the researcher, the participant and the interpreter; in these instances, the transcripts included the questions asked in English by the researcher and the answers provided by the patient, which were translated into English by the interpreter. All interview data were anonymized during transcription, and all transcripts were checked for accuracy by one

| Considerations when reporting participant demographics
Collection of data on a person's ethnic group is complex, as ethnicity is a multifaceted phenomenon. 42 There is a lack of consensus on what constitutes an ethnic group when, often, it is something that is self-defined and subjective to the individual. [43][44][45] Efforts were made to report a multitude of factors (including a person's first language, religion and citizenship status) to demonstrate the layers that accompany discussions about ethnicity. The UK Office of National Statistics 'Ethnic group, national identity and religion', 44 Table 1). Data reported also include a column for self-identified ethnicity and is recorded verbatim from participant interviews.

| Participant demographics
In total, 20 participants were recruited, including 16 UK citizens, 2 asylum seekers and 2 people in receipt of residency visas.
Participant characteristics are described in Table 1, and there were no refusals to partake, participant dropouts or repeat interviews. The

| Theme 1: Building knowledge and understanding about medication reviews
In all interviews, participants discussed challenges relating to awareness of medication reviews within ethnic minority communities; many reported being unaware of medication review services, which, understandably, impacted on their access. Reasons for this included a lack of knowledge and familiarity with the medication review process in the UK compared to that of their home country, as well as not understanding the benefits of the process. The use of peer-support networks and community signposting were discussed as potential strategies to overcome this. Participants viewed better advertising of medication reviews as a vital first step in supporting asylum seeker and refugee groups upon their arrival to a new country. Medicine-focused materials could be provided at this critical timepoint 'when someone is at their most vulnerable, they need to know where to go for these things… making sure (the medications) are prescribed, making sure they are safethat's all important' (Participant 19).

| Raising awareness through communitycentred support
Participants identified facilitators that could build awareness of medication review services within communities; by involving leaders from their community or religious groups, access to medication review services could be improved. Two participants discussed how their Rabbi (a qualified pharmacist) could 'indicate to the Jewish community, (medication reviews) is something we could be having to look after ourselves in a specific medicines-way… (whilst) adhering to the principles of our religion' (Participant 11). Similarities were discussed by Muslim and Sikh participants, believing that religious leaders could raise awareness of medication reviews. Signposting was also viewed as

| Theme 2: Delivering medication review services
The way in which medication review services are delivered was recognized as a priority when overcoming accessibility-related barriers.
Participants placed emphasis on addressing language and communication barriers between the healthcare professional and the patient.
Many discussed the ongoing impact on communication resulting from the COVID-19 global pandemic. Building patient-provider relationships through face-to-face services was perceived as a facilitator supporting access to medication reviews.

| Addressing language and communication barriers
Language and communication were raised as major barriers affecting people's access to obtaining medicine-specific advice. Fourteen participants reported that English was not their first language, and four participants contributed by using interpreters. Interviewees

| Face-to-face connections and reassurance
Forming a relationship between participants and healthcare professionals, through face-to-face appointments, was deemed to be an important facilitator to accessing services. One participant described a lack of connection when reviewing their medicines remotely,

| Acknowledging cultural beliefs and recognizing potential stigma
Challenges relating to cultural beliefs and stigma appeared to influence a person's readiness to access the diagnosis and treatment of certain medical conditions, most often mental health conditions. One participant, a member of the Orthodox Jewish community, discussed barriers to access for patients with 'any sort of mental health issues' as 'Jewish people are very, very closed about (mental health conditions)… when they come to marry, some people will be concerned' (Participant 11). They described how this may impact a person accessing medication reviews in fear of 'embarrassment' amongst the community (Participant 11).
People will not discuss it (mental health conditions)… especially if the pharmacist was a member of the community himself… that way it might become common knowledge and affect the family's reputation. (appreciating) the possible past-experiences that someone might have, because that isn't something they'll get over quickly. It's something that will be internalised and potentially affect them actually coming to (review their medications) if they know you'll be judgemental or not listen to them… show empathy… (take) time to listen. Participants from this study placed emphasis on the value of peer-support networks to overcome accessibility barriers to medication review services, similar to work in empowering ethnic minority groups through community outreach and signposting. 62 Religiousand community-based settings were discussed as places where medicine services could be advertised, recognizing the value of partnership-working when promoting health campaigns 63 to address inequalities in accessibility. 64 Cooperation between the public, healthcare professionals and community and religious leaders has been associated with empowering disadvantaged groups to access healthcare services. 62 This approach could cultivate culturally congruent healthcare environments and support the formation of culturally competent relationships between healthcare professionals and communities. 62,65,66 Success with peer-led support has been demonstrated pre-and postoperatively, 67,68 when managing longterm conditions 69 and in smoking cessation and weight management campaigns. [70][71][72] However, peer support has previously been associated with the dissemination of medical misinformation. 73,74 Findings from this review placed emphasis on digital peer support in the form of community WhatsApp ® groups and supported their use and acceptability. 75 Research should seek to gain further insight into digital interventions that may facilitate access to medication reviews for ethnic minority patient groups.
Participants identified the value in codesign alongside policymakers and healthcare providers when shaping future service design to improve the delivery of culturally competent medication review services. 76 Previous work identified the potential of pharmacy-based codesign approaches when engaging with marginalized groups. 77,78 Enhanced cultural competency of healthcare professionals supports the confrontation of inequalities in marginalized populations. [79][80][81] Understanding medication-related needs of ethnic minority communities, and the possible associated religious or cultural practices, may support greater appreciation of factors that influence medicine use. 79,82 Cultural competence training should be implemented in pharmacy curricula to widen knowledge of cultures within the populations they treat. 83 While this study offers insight into improving access to medication services, there remains a knowledge ROBINSON ET AL. | 1439 gap evaluating the extent to which addressing these factors results in improved health outcomes for ethnic minority groups in the long term. Collaborative work could support the development and refinement of a targeted medicine review intervention to support better access to medication reviews. 29,30,77 To further investigate the barriers and facilitators that would enable improved access to medication review services, future studies should seek to adopt codesign approaches to develop inclusive services that meet the needs of the communities. Consideration of this is also required for private healthcare settings, such as those in the United States, where financial reimbursement for such services may prove to be an additional barrier to their implementation. 84 The National Institute for Health Research (NIHR) toolkit and guidance from the NIHR INCLUDE project were used to support participant recruitment. 85,86 Members of the research team undertook cultural competency training delivered by the NIHR and Connected Voice. 86 Seven patient champions, who were representatives of the communities involved, were appointed to the research steering group and provided input ensuring cultural sensitivity throughout the research process, three of whom are listed as coauthors (L. S., T. G. and H. K. G.). The voices of numerous ethnic minority groups are included in this study; 20 participants of mixed ethnicities and age ranges were purposively sampled and interviewed. However, the authors acknowledge that there are some limitations with this study. The number of participants holding refugee and asylum-seeker status (n = 4) was outweighed by those who held UK Citizenship status (n = 16). The COVID-19 pandemic impacted participant recruitment, particularly with refugee and asylum-seeker groups, given funding and staffing issues on a charity level. The intended in-person data collection was also impacted; although 7 interviews took place in person, the remaining 13 used remote approaches. While remote interviewing holds many benefits, 87-89 user familiarity with video call software may have impacted its wider adoption amongst the study participants 90 ; although no differences were noted in the data collected across the different interview formats. 89 Family members supported as interview interpreters in this study; the authors acknowledged the potential limitations of this, given that the discussion was centred around medicines and health. 91,92 The focus of this study was ethnic minority populations living in the UK; thus, findings may not be generalizable in other countries. However, facilitating access is fundamental and must be considered to overcome global accessibility inequalities for ethnic minority communities.

| CONCLUSION
This study provides much-needed evidence of the barriers and facilitators that affect access to medication review services for people from ethnic minority communities. The results have important implications for overcoming ethnic inequalities. The data highlighted the significance of raising awareness of the medicine review services and understanding each person's lived experiences to address barriers that currently affect access. Delivering medication review services with cultural competency is vital; steps should be taken to address potential language barriers and build patient-provider relationships through in-person medication reviews. Collaborative coproduction approaches could enable better design, implementation and delivery of medication services that are accessible and culturally competent to best meet the needs of ethnic minority communities.